Provider Demographics
NPI:1063899862
Name:GRESHAM, KIMBERLY (OTR)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 E TWIN CREEKS TRL
Mailing Address - Street 2:
Mailing Address - City:TROUP
Mailing Address - State:TX
Mailing Address - Zip Code:75789-6708
Mailing Address - Country:US
Mailing Address - Phone:936-556-3756
Mailing Address - Fax:
Practice Address - Street 1:1001 WSW LOOP 323
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9416
Practice Address - Country:US
Practice Address - Phone:903-509-1313
Practice Address - Fax:903-509-1383
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114603225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist